Healthcare Provider Details

I. General information

NPI: 1023483914
Provider Name (Legal Business Name): BEULAH DENTAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2015
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W MAIN ST
BEULAH ND
58523-6970
US

IV. Provider business mailing address

PO BOX 118
BEULAH ND
58523-0118
US

V. Phone/Fax

Practice location:
  • Phone: 701-873-2259
  • Fax:
Mailing address:
  • Phone: 701-873-2259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateND

VIII. Authorized Official

Name: KEVIN B LEE
Title or Position: PRESIDENT
Credential: DDS
Phone: 701-873-2259